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PICO Methodology in Sepsis Treatment



Abstract

Concerns about the medical errors and quality of health care have been covered in both print and electronic media. State and federal legislators have discussed and proposed numerous legislations that aim at improving the quality of patient-oriented health care services. In one decade, quality of health care has been a primary focus of concern in the health care system. As a result, the health care system risk being over-burdened and failing to deliver safe, efficient, and patient-focused care that is required for optimal health outcomes at both personal and population levels. Without simultaneously addressing the quality of health-care services, expansion of access will essentially have little impact on the population health. However, there are the key issues that require utmost attention. This includes quality improvement and minimization of the medical errors.

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In this evidence-based research proposal, the paper will strive to find the ways of improving the quality of health care delivery, both inpatient and outpatient. Furthermore, extensive literature review will be conducted in order to understand the numerous ways of handling the issue under study. Numerous research questions have been devised to provide a roadmap for conducting the research. The study has also extensively borrowed from the various theoretical approaches, such as the Patricia Benner’s clinical wisdom approach. At the end of the research, the paper has eventually proposed solution to the problem, the implementation of the proposed plan, the mode of dissemination, and evaluation.

Evidence-Based-Practice Proposal

Introduction

Worldwide, momentum is growing for health care reforms that seek to improve the quality of healthcare services provided to all patients. Medical errors are the quality problems, which cause harm to millions of American citizens each year. If the errors were reduced, it would be possible to improve quality substantially. Therefore, it is imperative to develop the systems that anticipate unavoidable human errors and aim at preventing them before they cause harm to human health. However, formidable barriers now stand in the way of progress. Therefore, success will require a multifaceted strategy that includes government investment, regulation, and system restructuring within the health care delivery.

Problem Statement

The problem of the health services quality is widely discussed both among scholars and among the medical practitioners. The core issues, which deserve the additional attention, are the following: overuse of services and at the same time, misuse of others in terms of variety of the healthcare services available in the US. Nowadays, the main priority for the health care entities is healthcare services’ quality improvement and minimization of the medical errors (Sepucha et al., 2008).

Purpose of the Study

The core purpose of the research paper is finding the ways of the improving the diagnosis, prevention, and treatment services of health care delivery, both inpatient and outpatient service in order to maintain the existing strong points in the healthcare services provision, and to focus on the areas, which need improvement. For this purpose, the quality-measuring tests would be developed for further identification of the best ways for collecting and carrying out the comparison analysis of the obtained information in terms of quality. Afterwards, the effective improvement strategies would be developed.

Research Questions

In the process of conducting the research, the following problems have been identified:

Variation in services – there are both regional and small-area variations; underuse of services – it is estimated that annually 18,000 deaths in the US are caused by the lack of effective interventions. For example, studies have shown that only 20% of the patients with heart attacks receive beta-blockers (Earp et al., 2011). The third issue to be discussed is the overuse of services. Each year, the US citizens receive unnecessary costly health care services, which endanger the health condition of the patient. As an evident example, it is possible to consider the fact of overusing the expensive antibiotics for the treatment of various diseases. For instance, in case, if only 50% of prescriptions for the expensive antibiotics written in the timeframe of last 10 years had been written for the less expensive analogues (remedies of the equal effectiveness), the possibility of saving $400,000 annually would have occurred (Sepucha et al., 2008).

In the case of the practical implementation of the project, the following objectives would be achieved: generation of the strategy of the effective maintenance of healthcare services quality, which can potentially result in the provision of the effective services to the patients on time and lead to minimization of the medical errors. In addition, the option of saving money in terms of Medicaid provision may be obtained both for the American population and for the national programs. If the national healthcare programs involve using the effective and inexpensive remedies, the option of treatment of additional patients may be generated.

Question: How to improve the health and health care of patients, who lack the high-quality healthcare services, such as screening, treatment, and at the same time, minimizing medical errors?

It is essential to put an emphasis on the fact that the interventions cover the wide range of activities from the drug-treatment therapies to the lifestyle changes (such as exercises or particular diet); social activities may be also implied by the intervention, such as an education program. Furthermore, it is important to put an emphasis on the fact that both the individual patient care and the public health activities are implied by the intervention into the healthcare quality improvement; for instance, there is a need of screening such diseases as prostate or cervical cancer among the population.

P Population/patient = Patients with cancer, who lack screening services;

I Intervention/indicator = Cancer screening among the population;

C Comparator/control = No cancer screening;

O Outcome = Minimization of the medical errors, providing patients with the high quality screening healthcare services, which are effective for the treatment of their diseases.

P-Patient/problem - Sepsis in Emergency Room;

I-Intervention - Early goal-directed therapy (EGDT);

C-Comparison - Clinical decision system (CDS), the system is designed to assist physician in the decision-making tasks, such as diagnosis of patient data;

O-Outcome - primary: CDS improves the EGDT performance; barriers for efficient sepsis treatment can be overcome; early disease detection and care with no delays can be provided.

Clinical question: Which “approach” is more effective? All approaches, such as EGDT, derived from the articles’ review can be implemented jointly. This is because they present different angles of the issue and may improve sepsis treatment and early diagnosing of the infection and address the problem in a comprehensive manner.

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Literature Review

Introduction

The central focus of health care is the provision of high quality treatment. Nonetheless, there are many issues that are capable of influencing the quality of care delivered leading to the unfavorable consequences. The emergency room sepsis, often called “an intensive care unit (ICU) disease” (Rivers, Rubinfeld, Manteuffel, Dagher, McGregor & Mlynarek, 2011, p. 148), can be named among such acute problems. In general, the term “sepsis” is defined as systematic spread of an infection with manifestation such as fever, tachycardia, acute elevation in white blood cell count, and tachypnea (Berger, Birnbaum, Bijur, Kuperman & Gennis, 2010, p. 395).

This phenomenon may have dangerous complications, such as severe sepsis and sepsis shock. Many scholars, for example, Rivers et al. (2011), Berger et al. (2010), assert that this infection takes tenth place in the nationwide rate of the leading death causes, ranging approximately from 50% to 60%. The greatest problem is that this infection is hard to be diagnosed. Although certain policies and practices regarding addressing the issue function throughout the health care facilities, this concern is extremely topical and requires an immediate plan of action to be implemented or at least improved.

Therefore, this literature review is about synthesizing the evidence from the current studies regarding the issue in order to create an efficient and comprehensive framework for professional nursing practice. To achieve the aforementioned goal, certain steps will be taken.

  • Analyzing and reviewing articles on the different ways of improving the state of sepsis problem in the nursing practice;
  • Theoretical background related to the problem will be considered;
  • Specific approaches to make the situation better will be outlined.

Review

Berger, T., Birnbaum, A., Bijur, P., Kuperman, G., & Gennis, P. (2010). A computerized alert screening for severe sepsis in an emergency department patients increases lactate testing but does not improve inpatient mortality. Applied Clinical Informatics, 1, 394-407.

Level of Evidence

Based on the information reflected in the paper, it can be said that its evidence “obtained from well-designed controlled trials without randomization, quasi-experimental”; thus, are of level III (Melnyk & Fineout-Overholt, 2013).

Purpose

In the article by Berger et al. (2010), the current approach, to fight sepsis problem – early goal-directed therapy (EGDT) – in the scopes of emergency room is considered. Moreover, the way to improve it through its computerization – creation of a Clinical Decision Support system – is argued.

Design

The design of the study is defined by authors like “a quasi-experimental pre-post interventional design” (Berger et al., 2010, p. 396).

Sample Size

According to the set by the scholars criteria (age above 19, with sepsis meeting systemic inflammatory response syndrome (SIRS), etc.), 5,796 patients have been examined. In addition, nurses and physicians have been surveyed in order to investigate possible gaps in the EGDT.

Tools

General EGDT approach has been applied in its improved computerized form – emergency department CDS alert. In accordance with SIRS criteria, it became easier to detect sepsis in patients before complications develop. The program on the basis of lab tests identified whether the patient has sepsis or not. Statistical analysis has been performed via STATA version 10, Chi square tests, t-tests, and Mann Whitney U-tests.

Findings

As the study evidenced, it has been clarified that although EGDT has certain positive outcomes (34.4 % of mortality reduction), it still needs to be improved. The proposed by the researchers CDS system has become efficient tools for clinicians, since it has aided much in quicker diagnosing of sepsis, which, in turn, has led to higher survival of patients. As a result, an absolute death rate decrease of 34.4 percent has been noted.

Comment

The experiment paper is useful for clinicians in terms of defining the ways of improvement of sepsis screening and management in emergency departments. However, the scholars outline few limitations to their study. For instance, the absence of randomization, inability to address and research components of EGDT for severe sepsis has been indicated as barriers to the study. Besides, those aspects can become objectives for further exploration of the issue.

Burney, M., Underwood, J., McEvoy, S., Nelson, G., Dziebra, A., Kauari, V., & Chong, D. (2012). Early detection and treatment of severe sepsis in the emergency department: Identifying barriers to implementation of a protocol-based approach. Journal of Emergency Nurses, 38, 512-517.

Level of Evidence

The evidence collected in the article is of the third level, because those are not randomized and have been obtained from the well-designed controlled trials (though there was no experiment, but a survey analysis).

Purpose

The major goal of the paper is to clarify the gaps in the sepsis treatment conditions and the role of both physicians and nurses in this process, as well as to emphasize the measures to be put into action in order to address the issue collaboratively.

Design

This is a cross-sectional study investigating the correlation between the nurses and physicians’ roles in sepsis detection and treatment through the confidential online survey.

Sample/Size

What is interesting about this study, it is not patient-, but personnel-oriented. The sample involved 101 full-time staff nurses and physicians of emergency department (ED) of Columbia University Medical Center.

Tools

The basis for the analysis is an anonymous online questionnaire for practitioners in the above-indicated field. The analysis itself has been held with the use of PASW/SPSS version 18.0. Moreover, descriptive statistics and Pearson x? tests of independence have been applied.

Findings

The research has found certain common barriers to implementing a protocol-based EGDT approach:

  • The lack of access to the central venous pressure/central venous oxygen saturation monitoring (for physicians);
  • The lack of physical space to meet emergency demand leading to crowding and access block (for nurses);
  • Low awareness of the SIRS criteria in nurses and attending physicians;
  • A necessity to implement educational training for staffs concerning the problem and ensure inter-professional collaboration between nurses and physicians has been emphasized.

Comments

Notwithstanding the study is local-based (concerns one medical institution), it is a useful pattern for further researching of the problem, since many parallels in working conditions of personnel can be found within other health care institutions.

Rivers, E. P., Rubinfeld, I. S., Manteuffel, J., Dagher, G. A., McGregor, K., & Mlynarek, M. (2011, September). Implementing sepsis quality initiatives in a multi-professional care model. ICU Director, 2(5), 147-157.

Level of Evidence

This descriptive qualitative study presents evidence of the fifth level.

Purpose

The purpose of the exploration is to identify the links between the implementation of proper sepsis quality initiatives according to the different stages of care delivery (ED, general practice unit (GPU), and ICU) to minimize the negative outcomes of this infection’s treatment.

Design

The author has applied the qualitative study to explore barriers’, principles’, and models’ influence on the provision of sepsis care and treatment.

Tools

The article is a thorough analysis of EGDT implementation through the lens of an ED-base, a mobile ICU or medical emergency team (MET)-based, pharmacy-based, and completely ICU-based models. In addition, the article is illustrated with examples of sepsis screening sheets, as well as algorithms for better understanding of the issue and of the possible ways to its resolving.

Findings

Although the research does not distinguish any specified findings per addressing the problem, it becomes evident that a collaborative approach or “recognition of sepsis as a hospital-wide problem” (Rivers et al., 2011, p. 151) is extremely important in both addressing and further researching the problem.

Comments

The article explains the essence of different tools and approaches applied in the area. Therefore, it is of great significance for management, because of the implementation of proper sepsis treatment measures in all medical facilities, where sepsis conditions are most prevalent. This is because the author has recognized sepsis as a hospital wide problem.

Theory

There are many theories that explain the necessity and essence of nursing, as well as the ways of providing efficient care by these specialists. However, in this paper, the problem of sepsis in the emergency department will be analyzed through the prism of Patricia Benner’s clinical wisdom in nursing practice. As cited in the Masters (2012), “most of Benner’s work has focused more on understanding of perceptual acuity, clinical judgment, skilled know-how, ethical comportment and ongoing experiential learning” (p. 53). As a theorist and a practitioner, Benner has emphasized that patient and clinician relationships should involve engagement in a situation combined with a sense of membership in a profession.

This means that the relationship between patients and clinician should be very close, while, at the same time, involve a lot of professionalism. Moreover, the professional conduct is socially embedded, lived, and embodied in the practices, ways of being, and response to the clinical situations and ethical judgments are inseparable (Masters, 2012, p.54). Based on her practice and observations, she has identified seven directions of nurses’ performance (Masters, 2012, p. 54). These seven directions include:

  1. The helping role: in the case considered, nurses’ practice is to be aimed at helping patients in sepsis treatment through collaboration with physicians under the EGDT approach guide;
  2. The teaching-coaching function: nurses should educate their patients in terms of possible outcomes of the infection and its preventive measure. In this, teaching the patients on the sensitive groups in the population is essential;
  3. The diagnostic and patient monitoring function: Nursing practitioners ought to be well aware of the payments of this disease and be well qualified in order to ensure early detection of infection. In this case, CDS system may be used;
  4. Effective management of rapidly changing situations;
  5. Administering and monitoring therapeutic interventions and regimes. For example, Burney et al. (2012) emphasized nursing delays in terms of time completion of orders (p. 513). Thus, nurses ought to work collaboratively with physicians in order to ensure early and proper sepsis patient’s treatment;
  6. Monitoring and ensuring the quality of healthcare practices: Early diagnosis of sepsis is essential for the effective treatment. Nurses are first clinicians to examine patients, and this gives them a great chance to identify sepsis and “initiate a clinical pathway” (Burney et al., 2012, p. 516);
  7. Organizational work role competencies.

Additionally, Benner and her followers have outlined six aspects of critical care nursing (Masters, 2012, p. 54):

  • Reasoning-in-transition: This aspect regarding the sepsis issue has to be improved, since the studies reviewed indicated nurses’ low awareness level of the SIRS symptoms among others;
  • Skilled know-how: For instance, CDS system can become a useful tool in sepsis detection;
  • Response-based practice: Nurses ought to follow the improved version of EGDT protocol;
  • Agency: Whereas nurses are well-qualified and equipped for addressing the problem, they will have an ability to impact the situation and initiate a clinical pathway;
  • Perceptual acuity and the skill of involvement: The process of care has to be performed through the patients’ engagement in the treatment;
  • Links between clinical and ethical reasoning: This aspect involves a comprehensive collaboration between the different departments of healthcare institutions, which can provide the most positive outcomes for patients and reduce mortality levels significantly.

Therefore, to summarize the results of theoretical-literature review, the following ways to improve the care quality in terms of sepsis treatment can be proposed:

  • The currently maintained EGDT approach is efficient for addressing the issue, but it may be improved significantly; by assigning the patients, who arrive at an emergency department with severe sepsis or septic shock to receive six hours or EGDT before being admitted;
  • Applying the CDS systems in the ED will be an easier way to detect sepsis at the early stage and to initiate a clinical pathway;
  • A comprehensive inter-professional collaboration of both nurses and physicians in all departments involved in sepsis treatment (ED, GPU, and ICU) can provide patients’ treatment with no delays. This will help to increase patients’ survival rates;
  • In-depth educational programs related to the sepsis symptoms, treatment measures, and other multi-aspect concerns ought to be developed in order to ensure nurses’ high qualification in solving the problem.

Proposed Solution

Information is the most valuable resource today. Quick access to the appropriate information is vital in the several areas, including medical care. Time for information search is essential in medical care in order to react to the situation accordingly. Modern nurses are overloaded with duties and work; therefore, they may not be able to react to the situations appropriately, when quick response can save a patient’s life. Use of personal digital assistants (PDAs) in nursing is an important issue that can provide additional convenience and time for making the right decisions. It can be described as follows:

P (population/patients) - all patients;

I (intervention/indicator) - quick and correct reaction to a problem;

C (comparator/control) - slow or incorrect reaction to a problem;

O (outcome) - reduction of lethal cases and overall improvement of medical care quality.

It is necessary to evaluate the value of PDAs in nursing practice and to explore the ways these devices can influence the situation positively. Personal computers and computerized diagnostic systems were the first steps towards improving the flow of information and the diagnostic processes. Personal digital assistants (PDAs) and personal computers in the pocket are the next step to the improving process (smartphones can be used as well). These devices give a quick access to the medical records of any patient, medications ordering, and to the most up-to-date information in the medical area. Nurses are the first line of defense in the battle for a patient’s health and well-being; thus, the appropriate usage of PDAs in nursing is very important and sometimes even vital (Bland, 2010). The importance of quick access to the information for nurses cannot be overestimated.

The nursing profession is a combination of theoretical knowledge and practical skills that are aimed at providing efficient help in a timely manner. PDAs play an important role in this process (Johnson, 2008). Nurse can find the most updated information regarding various issues using the Internet, make appropriate notes in patient’s medical record, and order necessary treatment or drugs from the bedside. There is no need to get access to the stationary computer and lose precious time. PDA is a necessary tool for any nurse (White, Allen, Goodwin, Breckinridge, Dowell, & Garvy, 2005). Therefore, nurses should be equipped with PDAs and learn the ways to use them in an efficient manner.

Implementation Plan

Implementation of the proposed solution would require planning and efforts. It is necessary to evaluate the number of patients that require emergency services or quick help for the past 3 years. This will help in finding healthcare facilities requiring immediate changes. It would be needed to analyze the statistical data from the open sources, as well as contact healthcare facilities and to obtain such numbers from the inside.

  1. It is necessary to analyze the situation within these healthcare facilities and determine the primary factors caused deaths of such patients. It would be required to analyze the operations conducted within these hospitals in terms of efficiency;
  2. Top three hospitals should be chosen for a pilot project; their representatives should be contacted in order to propose the solution and to provide a rationale of the pilot project start;
  3. Personnel must attend the courses that will help them to learn the way PDAs can be efficiently used during their day-to-day activities. Organization of the courses will require resources for training the courses’ (hospitals will organize the place and hours for the training courses); organization-initiator of the projects will provide test PDAs and training specialists;
  4. After three months, the results should be revalued in order to see the way PDAs’ use affected deaths’ rate and overall quality of services – an analysis will be conducted as in step 1;
  5. Survey among patients and personnel should be conducted in order to determine the effect of PDAs’ use – an analysis will be conducted as in step 2 and survey specialists will be hired to conduct the quality research;
  6. In case of successful results, the implementation plan can be reconsidered in order to implement the proposed solution to other healthcare facilities.

Disseminating Evidence

According to the latest decay report, the public has lost their trust into the health care system. This is because many people end up dead in hospitals every day because of the medical errors, and those errors could be prevented. Excellence in patient care depends on the dissemination of evidences. Research Institute of Medicine published a report, where there were noted the six goals, which clinicians should follow. They state that care should be safe, efficient, patient-centered, timely, efficient, and equitable. There is a plan for dissemination evidence. Majority of research findings connected with clinical practice should be reviewed. Clinicians need to go through 19 articles in a day all year, day by day. Only this commitment to reviewing the latest evidence that guides their professional practice can regain the public’s trust. In the dissemination of evidence plan, it would be good to include one professional conference, where high-level health professionals have the opportunity to share their knowledge and experience.

Moreover, during this professional event the clinicians will be able to provide their knowledge and increase their own self-esteem. They can report the problem and its “who, where, and why” and propose the solution to the Professional organizations. The findings can be presented to the Association of Genetic Nurses and Counselors, American College of Medical Genetics, and Clinical Genetics Society; Journals: The American Journal of the Medical Sciences, and the Journal of the American Medical Association; Virtual Mentor - A Forum for Medical Ethics; Conferences: How to Overcome the Occurring Healthcare Industry Challenges, Clinical Reviews - 87th Annual, and Partners HealthCare 10th Annual Connected Health Symposium.

Conclusion

In conclusion, there are over 750, 000 new cases of sepsis in the United States. At least 210, 000 result to fatalities. As medication become more aggressive with invasive immunosuppression and procedures, the incidence of sepsis is likely to increase in the coming years. Reducing mortality as a result of severe sepsis will require an organized process, such as the one proposed in this paper. Additionally, this process should guarantee the early detection and recognition of sepsis along with the uniform and reliable application of proof based practices. There should be a clear model for the improvement of the current situation. An improvement team can be formed and help in establishing measures, as well as in selecting and testing changes.

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